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Gill Davey, incontinence nurse and spokesperson for Bladder Health UK, says: “Over the last 20 years, there has been a gradual shift in attitude around incontinence, and that’s mainly down to improved public awareness, thanks to TV advertising and celebrities speaking out.
"Incontinence is not a normal part of ageing. However, older people tend to exercise less, don’t drink enough and are on lots of medication, which are all risk factors. Pharmacies are key in helping to direct customers and giving good advice.”
At Essity (owner of the Tena brand), marketing director Ruth Gresty says: “Incontinence remains a taboo subject for many. Tena understands that supporting individuals with incontinence starts with destigmatising the condition. We aim to do that with direct communications and a wide assortment of products, to help individuals feel more comfortable.”
Numark medication safety officer and information pharmacist Jacquie Lee says: “Due to the prevalence of advertising for absorbent products, customers may assume that managing leakage is the only option. They may not realise that treatments, lifestyle modifications and behavioural techniques can significantly improve or even resolve the symptoms of overactive bladder and incontinence. By promoting awareness of available treatments, managing expectations and reducing the associated stigma, customers can be empowered to seek appropriate care and improve their quality of life, regardless of age.”
In May, the MHRA announced its decision to maintain POM status for the overactive bladder (OAB) medication Aquiette on safety grounds. The manufacturer of the oxybutynin-containing treatment, Maxwellia, expressed its disappointment with the decision. CEO Anna Maxwell said: “We’re incredibly disappointed with the MHRA’s decision not to improve access to a life-changing, low-dose, short-term overactive bladder medicine.
“Doctors who supported the reclassification believe that the MHRA has turned down an effective and easy way for women to treat their early stage OAB without the need for a prescription.” Maxwell added that although the reclassification opportunity has passed for now, the company would strive to innovate for OAB sufferers.
The Royal Pharmaceutical Society (RPS) was pleased with the MHRA’s decision, however. Laura Wilson, RPS director for Scotland, said: “Oxybutynin is a well established product with a known side effect profile. However, there is mounting evidence implicating the active ingredient with brain health harm, cognitive decline, the progression of dementia and greater mortality in those taking it. The extensive side effect profile of oxybutynin means that without access to patients notes, it could be challenging to determine its suitability in patients who do not fully disclose all current and previous medical diagnosis.
“Pharmacy teams do a great deal to manage safety, identify red flags prior to supply and ensure safe and appropriate use of P medicines. However, RPS does not believe that the balance of benefit and harm make this a suitable product for P medicine status.”
Numark’s lead information pharmacist Kenny Chan says: “Pharmacists are already stretched with their resources and time. Changing an item that has safety concerns to be available without prescription would require more time during the consultation process and may surface further questions from patients which pharmacists may not be able to answer.”
Bladder weakness in men
“Even with a high prevalence of men experiencing bladder weakness (one in four aged 40 plus), many still don’t feel confident seeking support,” says Tena’s Ruth Gresty. “Just 5-7 per cent of them buy purpose made products.”
Bladder Health UK’s Gill Davey agrees that men are often more reluctant to discuss incontinence than women. “However,” she adds, “as long as you broach the subject confidently and sensitively, they are usually quite open and grateful to be able to talk. You need to be approachable in your attitude to put men at ease.”
Gemma Barnes, specialist pelvic floor health physiotherapist at POGP, says there is a clear link between bladder symptoms and sexual problems in men, and that benign prostate enlargement and prostate cancer are two common reasons for men over 50 to experience bladder problems.
Expanding the pharmacy role
Gresty explains that there are three distinct groups of customers with incontinence needs that pharmacy teams should be aware of: women who experience bladder weakness and purchase products for themselves; men who experience bladder weakness and purchase products for themselves, and family caregivers. “Pharmacies are uniquely valued by family carers and 72 per cent prefer to shop for incontinence products in pharmacies rather than supermarkets,” she says.
Incontinence is still a sensitive topic for many, so needs careful handling. “It is always important to ensure any customer discussing their incontinence needs feels they can do so in a safe and unjudged environment,” says Gresty. She suggests asking ‘starter’ questions, such as whether leakage is occasional or continuous, whether the patient feels they haven’t fully emptied their bladder after urination, and whether they take any medicines.
Davey says it’s important to check with carers that their relative is taking their medication properly and to remind them of the importance of staying well hydrated. “If they want to buy pads for their relative, make sure they are buying the right level of absorbency and not just going for the maximum. If they use the highest absorbency and don’t need it, this can cause skin irritation.”
Lee has this advice: “Pharmacy teams should ensure that the customer can talk privately as they will need to feel at ease when discussing personal details about their symptoms. Showing patience and empathy and validating their feelings and concerns will help them understand that what they are experiencing is normal.
“Carers often experience emotional stress and challenges when caring for someone with bladder weakness or incontinence. Pharmacy staff can offer a supportive and empathetic ear, allowing carers to share their concerns, frustration, or anxieties.”
Self help advice to pass on
- Pelvic floor exercises are key. “Even people in a wheelchair can do them (unless they have nerve damage),” says Davey. “Pelvic devices are useful, but it’s best to get examined first to check what’s most suitable. They can help people gain more pelvic control”
- Take medication correctly. “If a customer is prescribed medicines such as anticholinergics, it’s important they stick with them as they take about four weeks to work,” says Davey
- Signpost your customers to a physiotherapist for more specialist advice on pelvic floor exercises and using pelvic training devices
- Drink plenty of fluids. Many people mistakenly believe they need to limit fluid intake if they have OAB or incontinence. Not drinking enough makes urine more concentrated, which irritates the bladder
- Address constipation as this can worsen bladder problems
- Only go to the loo when you really need to and lose the habit of going ‘just in case’
- Lose weight if needed. Even five to 10 per cent weight loss will help with incontinence
- Take regular physical exercise.
Pelvic floor exercises
Up to a third of women experience a problem with their pelvic floor muscles at some time during their life, according to POGP (the Pelvic Obstetric and Gynaecological Physiotherapy network), and stress incontinence is among the most common issues. The main causes of pelvic floor problems include pregnancy and childbirth; chronic constipation; heavy or repeated lifting; high impact exercise; obesity; chronic respiratory conditions; smoking, and menopause.
Helpful tips for customers
The POGP has this advice:
- Find a comfortable position – lying, sitting or standing. Contract your pelvic floor – think about squeezing at the anus as if holding in wind without clenching your buttocks. Hold the muscles tight and then release. Try to stay relaxed and don’t hold your breath
- Try to start squeezing for a count of five, then aim for 10 seconds eventually
- For fast squeezes, use the same action – lift and let go with no hold. Aim for 10 fast squeezes
- Ideally, do the exercises three times a day and use cues to remind you – set an alarm, exercise while you boil the kettle, while watching TV or sitting in traffic.
Views from the p3pharmacy panel
“This is an important area for us, especially with the older population, who have been having difficulty accessing other healthcare settings. Often, queries relate to differences in products and available sizes and the cost of similar products. Tena and Alvita are the most popular brands for our pharmacy. We try to place leaflets out in the store in an easy to access area when a new incontinence product is launched so we can highlight its benefits. We also offer free delivery if a customer is purchasing a large amount (e.g. over £100), as often these products are bulky.”
Shilan Shah, Mountford Pharmacy, Barnet
“This is an important category for men and women. We also get an increasing number of informal carers coming in to buy products for their relatives. People tend to self select. We get more questions about mattress and chair protectors than pads. They will ask about what absorbency they need. Tena and Attend continue to be our best sellers. I think people are becoming more comfortable talking about incontinence than they were. However, many men are still embarrassed about it. Put out all the different types of products you can so customers can see what you stock.”
Lindsey Fairbrother, Goodlife Pharmacy, Hatton, Derbyshire
“This isn’t a very popular area with our customers and we don’t have a large area of space to display the products, which can be quite bulky. However, we do order in products for customers. We get asked mainly about the different types of pads and which are best suited to the customer’s needs, but more often we’ll get asked about medication for bladder weakness, which customers are becoming more aware of. Most popular products are Tena and incontinence medication Flomax. I’ve noticed that, gradually customers have become more confident at discussing bladder weakness with us.”
Sarina Mughal, Day Lewis, Knightsbridge
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